Possible Lessons from Peacock

[Rice]

Originally this thread was part of a larger thread ostensibly about an accident in Peacock Springs. It has gone off in several directions, and this thread is one of them. Since it is a split, the posts may not flow smoothly; feel free to ask for clarification. Some posts are deleted - if you find one of yours missing from all four threads and you *really* feel it's important, and you don't want to try to reconstruct your thoughts - PM me and I'll see what I can do.
The four threads are
Peacock Springs Fatality - Accidents & Incidents
Peacock Springs - Cave Diving
Possible lessons from Peacock - Cave diving
Accountability in accidents - Basic Scuba Discussions

Rick

I heard on the radio this afternoon of a death at peacock springs Florida. Apparentley (from the radio) the non-cave trained diver was diving with friends. He signalled that he was low on air, they then had to search for him for over an hour. (huh?)

Details were sparse, obviously

I hope that by talking about incidents like this we can reduce these kinds of accidents. In the end it's just a sad, preventable loss.
rice

 

[Squalus]

I heard on the radio this afternoon of a death at peacock springs Florida. Apparentley (from the radio) the non-cave trained diver was diving with friends. He signalled that he was low on air, they then had to search for him for over an hour. (huh?)

Details were sparse, obviously

I hope that by talking about incidents like this we can reduce these kinds of accidents. In the end it's just a sad, preventable loss.
rice

There are a couple here monitoring this incident, not to speculate till confirmation what certification he had. They will post when factual evidence is made.

 

[jeandiver]

I saw Shelley's article/report on another forum...(sigh...)

My condolences to the family and to his friends...

Jean

 

[ShakaZulu]

Sad to read about this........how many times does this happen whe a diver leaves without his buddy.

 

[GDI]

I hate assumptions and I can only imagine the possible fallout that may come of this. I will will pray for the family. The report (IUCRR) will not answer the questions that many of you have at this time. The police I am sure will investigate as they do for any such accident and from that a report may come and policy's may change. For now just think about it to yourself and as far as a public forum is concerned let it go short of passing on your condolences to family.

 

[jjoeldm]

I hate assumptions and I can only imagine the possible fallout that may come of this. I will will pray for the family. The report (IUCRR) will not answer the questions that many of you have at this time. The police I am sure will investigate as they do for any such accident and from that a report may come and policy's may change. For now just think about it to yourself and as far as a public forum is concerned let it go short of passing on your condolences to family.

Then what exactly is the point of this forum?

The only way a dive community will ever do anything about this sort of incident is if they talk about it. There is a way to do it. State the facts as they are known and discuss them.

If any of you have actually read Sheck Exley's Blueprint for Survival, the genesis of Cave Diving Accident Analysis, you will know that finding out what went wrong isn't just about determining if there is some "unfortunate bad luck" or some blameless circumstances. It's also about assigning blame if there is blame to assign. UWS had an excellent article in it entitled "BEYOND MAXIMUM STUPID" back in the early 90's that described a dive in which two divers did a sidemount dive using one cylinder, one set of fins and weights and monofilament line. They were found OOA and wrapped like a fly in a spider web inside the cave. There was a graphic in that article, a drawing of a meter, a "stupidometer." The two highest settings were "dead meat" and "beyond maximum stupid."

I'm not saying that the deceased was stupid here. He was a student no doubt following the guidance and "wisdom" of his instructor. When I was a cavern diver in 1990 I idealized my instructor. I might have done whatever he said was OK to do. That comes with the territory. After all, I was following him into a water-filled cave, how much more dumb could I be? It's why OW students follow their non-cave instructors into water-filled caves and die even though their manual and the test they took clearly says not to.

I'm just so sick of reading about these completely pointless deaths, deep on air, solo, uncertified cave, diving beyond your level of competence, experience and training. Someone, somewhere along the way has to be responsible for some of these. People make bad decisions, sometimes criminally bad decisions. These are not all just "accidents" and it's time we stopped tippy-toeing around it, especially in a forum entitled "Accidents and Incidents." Sometimes it is a series of unfortunate events, something missed, but even those have a cause, a chain of events that lead to the fatal moment.

I've heard other times that the "report will be released" that will answer everything and then you never hear another word. Maybe it did get published . . . somewhere. On the positive side, the IUCRR (www.iucrr.org) has published 20 reports. Since 1950, if Bozanic's study is correct, there have been nearly 500 deaths up to 1998. I can glean back issues of UWS and find more than that number of 20. I'd like to see them do more. I'm not faulting the IUCRR. I respected Henry Nicholson tremdendously and liked him personally. But I'd like to see every accident report be published. Every cause and what led up to it, because I know that the one document that had the greatest impact on me as a cave diver was Exley's little Blue Book.

He said he got the idea from graphic, horrible photos of accidents posted at a rest stop to shock motorists into slowing down. It worked, on Sheck and on me. I followed the rules to the best of my ability and I always wondered, "have I ever read anything like this on an accident report"? And so I always dived conservatively. I haven't run much new line, no, but I've done some great dives to some virgin and almost virgin places because I always tried to keep those lessons in mind.

I always wonder how many lives might be saved if, all these years, the CDS and the NACD and the IUCRR had been publishing every accident in detail like the ones in Sheck's book. Has anyone? If so, I'd love to know where it is. I read a lot of these reports in the early UWS' and I have always thought that if there were a searchable database of accident reports published online minus names, but with accurate details, then there'd be more divers who'd say, "Wow, I've done THAT before!" and maybe they'd be alive now.

They exist, all those reports. And the more they are talked about and passed around and made a part of fabric of tech diving instead of the "I scootered to the Hinkle on my 50th cave dive -- and survived!!!" BS, the fewer divers would be dead. Cave Diving is macho enough, let's let a little reason and temperance seep back in.

There will always be bad judgement, but self-censoring is not the answer. So long as the discussion is as factual as possible, devoid of profanity and on point, you can't do wrong in a forum dedicated to discussing accidents. I don't believe that victims families really belong here. Not if they will be hurt by discussion of their loved ones. There are better places to be right now. I'd suggest that they ask someone to keep them posted on events. Certainly that newpaper article was a lot more graphic than anything said here thus far. This forum should have a disclaimer, "Graphic discussions of diving accidents. Do not enter if you find such discussions disturbing." If PBS can do it and discuss and show horrible events on television that is beamed passively into the living rooms of millions, surely a forum entitled "Accidents and Incidents" can do as well.

But then it's not my forum. But it is my sport. So if you're going to discuss accidents then do it, otherwise, call it the Empathy Forum or the Condolences Room. But if doing anything but offering condolences is in bad taste, then this isn't an Accidents Forum. Or so I think . . . .

JoeL

 

[GDI]

Then what exactly is the point of this forum?

The only way a dive community will ever do anything about this sort of incident is if they talk about it. There is a way to do it. State the facts as they are known and discuss them.

If any of you have actually read Sheck Exley's Blueprint for Survival, the genesis of Cave Diving Accident Analysis, you will know that finding out what went wrong isn't just about determining if there is some "unfortunate bad luck" or some blameless circumstances. It's also about assigning blame if there is blame to assign. UWS had an excellent article in it entitled "BEYOND MAXIMUM STUPID" back in the early 90's that described a dive in which two divers did a sidemount dive using one cylinder, one set of fins and weights and monofilament line. They were found OOA and wrapped like a fly in a spider web inside the cave. There was a graphic in that article, a drawing of a meter, a "stupidometer." The two highest settings were "dead meat" and "beyond maximum stupid."

First of all you don't have all the facts and many people here are speculating and making assumptions.Some facts are known I will give you that.
The point of Accident Analysis is TO SAVE LIVES FROM LESSONS LEARNED It HAS NOTHING TO DO WITH ASSIGINING BLAME

Training
Guidelines
Air
Depth
Lights
There is no point about assigning blame. Discuss it on these points only.

I'm not saying that the deceased was stupid here. He was a student no doubt following the guidance and "wisdom" of his instructor. When I was a cavern diver in 1990 I idealized my instructor. I might have done whatever he said was OK to do. That comes with the territory. After all, I was following him into a water-filled cave, how much more dumb could I be? It's why OW students follow their non-cave instructors into water-filled caves and die even though their manual and the test they took clearly says not to.

Yes agreed this a common fault of both instructors and students and it is here that instructors need to teach their students that certification limits are in place for a reason and that students should not blindly follow anyone.

I'm just so sick of reading about these completely pointless deaths, deep on air, solo, uncertified cave, diving beyond your level of competence, experience and training. Someone, somewhere along the way has to be responsible for some of these. People make bad decisions, sometimes criminally bad decisions. These are not all just "accidents" and it's time we stopped tippy-toeing around it, especially in a forum entitled "Accidents and Incidents." Sometimes it is a series of unfortunate events, something missed, but even those have a cause, a chain of events that lead to the fatal moment.

Yes we all are.
I'm not suggesting you personally but in general It just amazes me how everyone here comments on how bad the other diver is, how their training was obvisously wrong, the dangling gauges, the incorrect bouyancy and trim, the poor propulsion techniques, how they observe divers going on dives far beyond their experience, training and certification levels. Yet no one seems to step up and talk to these divers, talk to their buddies and even make an attempt to stop them from placing themselves in harms way. Oh yes we will make everyone know just how good a diver or instructor we are and we will tell them this in the most arrogant and boisterous manner. I too am most likely guilty of this, I vouch to change. There have been to many deaths this year, one death is to many.

I've heard other times that the "report will be released" that will answer everything and then you never hear another word. Maybe it did get published . . . somewhere. On the positive side, the IUCRR (www.iucrr.org) has published 20 reports. Since 1950, if Bozanic's study is correct, there have been nearly 500 deaths up to 1998. I can glean back issues of UWS and find more than that number of 20. I'd like to see them do more. I'm not faulting the IUCRR. I respected Henry Nicholson tremdendously and liked him personally. But I'd like to see every accident report be published. Every cause and what led up to it, because I know that the one document that had the greatest impact on me as a cave diver was Exley's little Blue Book.

Shecks book is recommended as and should be required reading for all divers. The IUCRR reports will not answer every question out there. The reports are structured in format as to what information is gathered and answered. The authorites investigation handles the rest.

He said he got the idea from graphic, horrible photos of accidents posted at a rest stop to shock motorists into slowing down. It worked, on Sheck and on me. I followed the rules to the best of my ability and I always wondered, "have I ever read anything like this on an accident report"? And so I always dived conservatively. I haven't run much new line, no, but I've done some great dives to some virgin and almost virgin places because I always tried to keep those lessons in mind.

I always wonder how many lives might be saved if, all these years, the CDS and the NACD and the IUCRR had been publishing every accident in detail like the ones in Sheck's book. Has anyone? If so, I'd love to know where it is. I read a lot of these reports in the early UWS' and I have always thought that if there were a searchable database of accident reports published online minus names, but with accurate details, then there'd be more divers who'd say, "Wow, I've done THAT before!" and maybe they'd be alive now.

They exist, all those reports. And the more they are talked about and passed around and made a part of fabric of tech diving instead of the "I scootered to the Hinkle on my 50th cave dive -- and survived!!!" BS, the fewer divers would be dead. Cave Diving is macho enough, let's let a little reason and temperance seep back in.

There will always be bad judgement, but self-censoring is not the answer. So long as the discussion is as factual as possible, devoid of profanity and on point, you can't do wrong in a forum dedicated to discussing accidents. I don't believe that victims families really belong here. Not if they will be hurt by discussion of their loved ones. There are better places to be right now. I'd suggest that they ask someone to keep them posted on events. Certainly that newpaper article was a lot more graphic than anything said here thus far. This forum should have a disclaimer, "Graphic discussions of diving accidents. Do not enter if you find such discussions disturbing." If PBS can do it and discuss and show horrible events on television that is beamed passively into the living rooms of millions, surely a forum entitled "Accidents and Incidents" can do as well.

But then it's not my forum. But it is my sport. So if you're going to discuss accidents then do it, otherwise, call it the Empathy Forum or the Condolences Room. But if doing anything but offering condolences is in bad taste, the this isn't an Accidents Forum. Or so I think . . . .

JoeL

Good Points
(However IMO) We need to discuss these accidents without names or blame. The fact is that most of the comments mentioned here are not often factual. It is a public board and family will access these discussions and no one wants to read how stupid their loved ones were comments made by some unknowing individual. Look at the known events, look at and study the possible causing circumstances and learn from them- That is Accident Analysis.

 

[MikeFerrara]

First of all you don't have all the facts and many people here are speculating and making assumptions.Some facts are known I will give you that.
The point of Accident Analysis is TO SAVE LIVES FROM LESSONS LEARNED It HAS NOTHING TO DO WITH ASSIGINING BLAME

I agree except I haven't seen any accident analysis more recent than Sheck's book. We get initial report and everything dies. So many of the accidents I've seen or read about are "out there" that I just can't believe that there aren't issues being addressed by...some one?...agency, DAN, instructors? We se the same stuff over and over so maybe there's very little need for much analysis huh?

I agree that in pure analysis names should be left out. The only problem I have is that there are instructors I know who at the very least contributed to one or more deaths and they're still teaching! They still own or run dive shops! they're going to get some one else! Personally I have no preoblem with a diver who just decides that he's good enough without training and does what he wants...then it's on him and him alone. However we go so far out of our way to market diving as safe and lull people into trusting instructors and agencies. Some of the dumbest things I've seen or heard of divers doing was done while following a DM or instructor. then some one dies and we hold hands to comfort every one and there's no accountability.

Training
Guidelines
Air
Depth
Lights
There is no point about assigning blame. Discuss it on these points only.

Training...he didn't have it and either wasn't getting it at the time or they were breaking all the standards.

Guidlines...Since he jumped to another line without installing a jump reel or spool a continuous guidlint to the surface was not maintained.

Air...he ran out

Depth..185 on air is an END of 185 which sort of blows away the 130 thing.

Sounds like he may have been ok in the lights department.


This is the second instance I know if in a year and half or so where a diver, known to low on gas or out of gas disappeared and the rest of the team just left the cave. In my cave class we practiced lost buddy searches and talked about seperations. I was taught that if I was seperated and felt the need to head for the door alone to put a note on the line. So...if we're ever diving together and some how get seperated and you don't see one of my wet notes on the line, gas permitting, please take a few minutes to look for me.

I'm not suggesting you personally but in general It just amazes me how everyone here comments on how bad the other diver is, how their training was obvisously wrong, the dangling gauges, the incorrect bouyancy and trim, the poor propulsion techniques, how they observe divers going on dives far beyond their experience, training and certification levels. Yet no one seems to step up and talk to these divers, talk to their buddies and even make an attempt to stop them from placing themselves in harms way.

Now Rick, I believe these things fall under rule ONE training. Personally, I not only talk to divers about it but also instructors. I have talked with a few at dive sites and a bunch in classes I taught but I get to talk to orders of magnitude more here. One single post is read by more divers than I'll ever meet face to face in a lifetime. If only a tiny percent give it some thought the potential is still great.

Shecks book is recommended as and should be required reading for all divers.

Most cave divers are introduced to it but few others. I think the DAN report should be required reading for all new divers to. I also think there should be reports published on accidents like the one where an overweighted student slipped off a platform...sunk to 60 ft and blew out her ear drums...or the one where the lady drowned with a full tank 5 ft below the surface tangled in kelp while her 2 dive buddies waited for her on the bottom...duh.

Yes some of these are silly mistakes made by individuals but are they really being taught any better by any one? How many divers think it's unusual for a group to descend and meet at the bottom. They see it right from their OW class even though ascents and descents are amoung the most likely times in a dive to have a problem...it's also when divers are often solo.

We don't see differnt accidents. We're see that same 2 or 3 variations over and over and no one is learning anything. It's like watching a movie. 5 minutes into it you know the plot because there's only a couple of basic plots that have ever been filmed. Same here.

Good Points
(However IMO) We need to discuss these accidents without names or blame. The fact is that most of the comments mentioned here are not often factual. It is a public board and family will access these discussions and no one wants to read how stupid their loved ones were comments made by some unknowing individual. Look at the known events, look at and study the possible causing circumstances and learn from them- That is Accident Analysis.

The one advantage to leaving names out is that people will be more willing to talk and let the facts out. All instructors know that when things go wrong you give the facts to the insurance company and then let them or your lawyer do the talking.

Even so...it's all wasted time because the ones who need to hear the story likely won't and the agencies in general will never act. Training is only modified to get more through. Even cave diving is getting to be big business. It's a great sport let every one enjoy it and I'm all for free enterprise but as Te Nugent said..."wack em...pack em...and stack em".

IMO, we need detailed analysis and it needs to be shoved in divers faces from the moment they begin training. We need to stop with the "In the unlikely event that..." BS and tell divers that if you dive poorly it's not so darned unlikely and you're relying on luck. Chit doesn't just happen. We make it happen or let it happen. We can't ever be perfect or avoid all mistakes but we should do ok at avoiding most of the really simple ones. We should sure be able to avoid making the same really simple mistakes over and over...but we're not.

Sorry to digress in to rec stuff. Just delete it if you want.

 

[Bobby]

I agree except I haven't seen any accident analysis more recent than Sheck's book. We get initial report and everything dies. So many of the accidents I've seen or read about are "out there" that I just can't believe that there aren't issues being addressed by...some one?...agency, DAN, instructors? We se the same stuff over and over so maybe there's very little need for much analysis huh?

Mike,
Actually there is on going analysis right now. There were two additions to Shecks original factors and there are a host of things that are being looked at today. In addition there is on going analysis to line protocol, training procedures, and a host of other things. At the moment it is not published because the work is not ready yeat. The amount of time and effort it takes to make sure a change is correct and worded properly is daunting.

I agree that in pure analysis names should be left out. The only problem I have is that there are instructors I know who at the very least contributed to one or more deaths and they're still teaching! They still own or run dive shops! they're going to get some one else! Personally I have no preoblem with a diver who just decides that he's good enough without training and does what he wants...then it's on him and him alone. However we go so far out of our way to market diving as safe and lull people into trusting instructors and agencies. Some of the dumbest things I've seen or heard of divers doing was done while following a DM or instructor. then some one dies and we hold hands to comfort every one and there's no accountability.

No comment due to lack of experience on the subject as far as instructor cards being or not being pulled. I do agree with the marketing thing and that has stemmed from the drive to compete with other sports for disposable income such as sking (more dangerous IMHO) and the such.

Training...he didn't have it and either wasn't getting it at the time or they were breaking all the standards.

Guidlines...Since he jumped to another line without installing a jump reel or spool a continuous guidlint to the surface was not maintained.

Air...he ran out

Depth..185 on air is an END of 185 which sort of blows away the 130 thing.

Amen

This is the second instance I know if in a year and half or so where a diver, known to low on gas or out of gas disappeared and the rest of the team just left the cave. In my cave class we practiced lost buddy searches and talked about seperations. I was taught that if I was seperated and felt the need to head for the door alone to put a note on the line. So...if we're ever diving together and some how get seperated and you don't see one of my wet notes on the line, gas permitting, please take a few minutes to look for me.

I was never taught that and I like it. I will now put it in my predive checks with my buddies, thank you.

We don't see differnt accidents. We're see that same 2 or 3 variations over and over and no one is learning anything. It's like watching a movie. 5 minutes into it you know the plot because there's only a couple of basic plots that have ever been filmed. Same here.

IMO, we need detailed analysis and it needs to be shoved in divers faces from the moment they begin training. We need to stop with the "In the unlikely event that..." BS and tell divers that if you dive poorly it's not so darned unlikely and you're relying on luck. Chit doesn't just happen. We make it happen or let it happen. We can't ever be perfect or avoid all mistakes but we should do ok at avoiding most of the really simple ones. We should sure be able to avoid making the same really simple mistakes over and over...but we're not.

Actualy this one has a very bad twist in it though most of the theme is the same as other accidents. I agree with being more upfront with divers from the time of OW but as said earlier the industry is trying to compete in the disposable income arena and it would be very hard to get a starving instructor that probably has minimum training himself and trying to eek out a living to uphold to that standard, much less get the agencies to go in that direction. Too many would be scarred off impacting the bottom line.

Just some of my thoughts, nice post.

Bobby

 

[jjoeldm]

Look around orange grove cavern.. look around P1. And now try to explain the concept of the need to be careful about your bouyancy, trim, silt, the need to be extremely aware of all your surroundings.

Now take that explination, and put the diver in the P3 cavern.

When I rounded the bend later in my diving career; silt didn't phase me, because I knew that the peacock I cavern is -not- what a cave looks like... P3 is. P3 emphasised the importance of prevention of silt disturbance.

With an instructor with a clue, and students who have the base skills down, and the right conditions, p3 can be a very powerful site for students.

Whether or not PIII is appropriate for cavern training (and personally, I think there is no lack of equally challenging places that are better suited -- but that's another discussion), the basic fact is that we have a cavern diver diving in a very advanced system. Peacock III is not really much of a cavern dive. Sure, as has been pointed out, it might be a pretty little cavern, but that's the operative word here, "little". Nor is it really an intro dive IMHO. Here are the "limits of training" for the CDS:

A. Penetration is limited to one-third (1/3) of a single diving cylinder, or one-sixth (1/6) of twin cylinders.
B. Penetrations are limited to simple linear swims only. No complex navigation or dive plans.
C. 100 feet maximum depth.
D. 30 feet visibility.
E. No restrictions (any area smaller than that which can be negotiated by two divers swimming together).
F. No decompression diving.
G. No original exploration or goal-setting should be attempted at this level of training, and task-oriented diving is discouraged.

Let's score this dive assuming this diver was an intro candidate and the instructor leading (we assume he was leading) the dive was his instructor:

A-- FAIL
B-- FAIL
C-- FAIL
D-- MARGINAL (35-40) PASS
E-- FAIL
F-- FAIL
G-- FAIL

So of seven standards, assuming this diver was actually IN a course, this instructor apparently failed to meet six of them and for my money, as silty and as dark and as low as that place is, the seventh was a "fail" as well.

So my opinion is that it's irrelevent what course he was in because he was equipped for an Intro course and as a cavern diver, EVEN IF HE WAS ENROLLED IN A COURSE FROM INTRO TO FULL CAVE, he was equipped as an Intro diver and therefore should not have been diving outside the Intro guidelines and Peacock III is not an Intro cave. But the fact is, his instructor is listed on his agency's site as an Intro Instructor, so he had no chops to train him further than that anyway.

And if he wasn't in a course, was just a cavern diver? Wow! I think we can fill that in.

As far as how he became separated or the whys or whatfors of whether he zigged when he should have zagged as some have suggested, I think is missing the point. This isn't a "gee how did this guy get in trouble in there" accident, this is a "cavern diver in a very advanced, deep, dark, silty full-cave dive" accident. The rest is "how many angels can fit on the head of a pin" stuff.

And as far as "deep" or "extended range" training in a cave, this is 190' in an advanced-deep-dark-silty-very-restricted-water-filled-cave. No one should be doing "deep" training here except as part of a very advanced Full Cave course and they should be using the proper gas.

If God had wanted us to dive deep in caves he would have given us Helium and ordained his flock to train us . . . oh, right, he did.

More on AA later . . . . : )

JoeL